Medical History Questionnaire

First Name *

Last Name *

Mobile Phone *

Email *

Date of birth *

Street Address *

City *

State *

Country *

Postal code *

Occupation *

Who referred you to our office? *

In case of emergency, we should notify:

Emergency Contact Name *

Relationship to Emergency Contact *

Emergency Contact Day-Time Phone *

Please list all medical specialists you are seeing, including your primary care physician:

Name of Family Doctor

Family Doctor Phone or Address

(1) Name of Medical Specialist

Area of Specialty

Phone or Address

(2) Name of Medical Specialist

Area of Specialty

Phone or Address

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.

1) Are you currently being treated for any medical condition or have you been treated within the past year? If yes, please explain? *

Yes

Not Sure / Maybe

Please explain *

2) When was your last medical checkup? *

3) Has there been any change in your general health in the past year? *

Yes

Not Sure / Maybe

Please explain *

4) Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, please list them. *

Yes

Not Sure / Maybe

Please explain *

To the best of my knowledge, the above information is correct:

Please sign here *

Clear